The fault in our stars

by PAULA SPAN

If looking for a nursing home weren’t confusing and dispiriting enough — often undertaken in a hurry when a discharge planner announces that, ready or not, your relative has to leave the hospital — check out this perplexing finding from Ohio:

Of the state’s nursing homes ranked one star (“much below average”) on Medicare’s Nursing Home Compare online report card, most residents interviewed face-to-face rated their satisfaction as low or very low — yet close to one in five gave these supposed losers high marks. So did 20 percent of the families interviewed.

On the other extreme, in Ohio nursing homes that Medicare rated five star (“much above average”), a majority of residents ranked their satisfaction as very low, low or moderate, and about 40 percent of families expressed similar discontent.

The back story: In 2008, after Senator Ron Wyden, Democrat of Oregon, complained that it was easier to find consumer information about washing machines than nursing homes, the Centers for Medicare and Medicaid Services beefed up its online guide, providing the familiar one-to-five star ratings used for restaurants and movies.

It may be that they do well in terms of cleanliness, but the staff doesn’t treat people respectfully, so residents don’t like living there.

Consumer advocates have warned ever since against relying solely on those stars to choose nursing homes. People still need to visit, ask questions, talk with other residents and families. The inspection reports, staffing data and quality measures on the Medicare site offer more specific information than the stars. (Nursing Home Inspect, the online tool developed by ProPublica, lets you drill down even further.)

Still, you would expect fewer stars to equal less satisfaction, with more stars making residents and families happier. In a large Ohio study, just published in The Gerontologist, that’s generally true but not consistently.

Medicare itself doesn’t measure consumer satisfaction, though it has added a few resident questions to its annual nursing home surveys. A handful of states collect data from residents or family members, but only Ohio and Rhode Island talk to both.

Ohio’s Long-Term Care Consumer Guide, which Dr. Applebaum helped begin in 2001, gathers responses from families and residents in alternate years. For this study, he and his colleagues used data from 955 Ohio facilities: almost 30,000 surveys mailed by family members (a 47 percent response rate) in 2010 and nearly 23,000 face-to-face interviews with residents in 2009.

Comparing those responses with Medicare’s stars, they found that satisfaction scores didn’t differ significantly by every star: There was little difference in satisfaction between one star and two, say, or between four and five. And as I mentioned above, consumers were fairly often at odds with the starred ratings, expressing satisfaction with supposedly low-quality homes and disliking high-quality ones.

One reason, Dr. Applebaum said, is that the state surveys Medicare relies on measure clinical things, like how often pressure sores occur or whether facilities handle food properly. “It may be that they do well in terms of cleanliness, but the staff doesn’t treat people respectfully, so residents don’t like living there,” he said.

Moreover, families’ and residents’ satisfaction scores often differed. “Families are concerned about safety and amenities,” Dr. Applebaum said. “Does the place smell? Do the nurses look professional?

“The person who lives there is much more concerned about being treated in a certain way, having some control, being able to do what they want to do,” he added. “They don’t care about the chandelier in the lobby. It’s, ‘How does the person who comes to help me use the bathroom treat me?’”

For patients undergoing short-term rehab, a growing proportion of nursing home residents, these findings may not matter much. It’s different when a nursing home becomes, simply, home.

The Miami University researchers argue that the Centers for Medicare and Medicaid ought to incorporate consumers’ opinions in its star rankings. Yes, Dr. Applebaum acknowledged, that would add costs, and “nobody wants to do that in this day and age.”

But, he said, “if you’re really trying to give consumers information to make choices, not including resident and family satisfaction is a serious limitation.”

It’s like publishing a Michelin guide, he said, that rates how clean a restaurant’s kitchen is and calculates whether there are enough waiters, but pays no attention to how good the food is.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”